Camp Conservation Registration Forms Home About Schedule Forms Album email Newberry Soil And Water Conservation District USDA Service Center, 719 Kendall Road, Newberry, SC 29108 Phone:803-276-1978 Ext. 3, Fax: 803-276-7887 *2008 NOTICE* If your computer settings do not find these forms to be "Printer Friendly" printing from the web page... Then you may download the .pdf version for printout here ... 2008 Camp Application.pdf YOU MAY PRINT THESE FORMS FROM THIS WEB PAGE AND SUBMIT FOR APPLICATION NOTE: IF SUBMITTING FORMS FROM WEBSITE PLEASE PRINT AND SIGN "RULES ACKNOWLEDGE FORM" ON "ABOUT" PAGE AS WELL! Registration Form Camper's Name: ________________________________________________________________ Mailing Address: ________________________________________________________________ City: ________________________________ State:____________________Zip:__________________ E-mail adrress :______________________________________@____________________________________ Age: 9 10 11 12 How many years have you attended CAMP CONSERVATION ?   1     2     3     4     5 Sex:     Male   Female School: __________________________________________________________________________ Mother's Name:_________________________________________________________________ or Guardian Home Address: __________________________________________________________________________ City: ____________________________________ State:________________Zip:_________________ Home Phone # (________) _______-___________ Cell Phone # (________) _______-____________ Work Phone # (________) ________-__________ Pager # (________) _______-___________ Employer's Name: ____________________________________________________________________________ Work Address: ___________________________________________________________________________ City: _________________________________ State: ______________ Zip: __________________ Father's Name:____________________________________________________ Home Address: __________________________________________________________________________ City: _______________________________ State: ______________Zip:____________________ Home Phone # (______) _______-_________ Cell Phone # (______) _______-__________ Work Phone # (______) _______-__________ Pager # (______) _______-__________ Employer's Name: __________________________________________________ Work Address: ___________________________________________________ City: ________________________________ State: _______________ Zip: _____________ Other CONTACT INFORMATION: other than the names and numbers listed above ... Please provide additional persons to contact should you not be available. Name: ____________________________________ Relationship to child:______________________________ Phone #: (______) _______-_________     CELL Phone: (______) ______-__________ Name: ____________________________________ Relationship to child:__________________________________ Phone #: (______) _______-_________     CELL Phone: (______) ______-__________ EMERGENCY MEDICAL RELEASE FORM Student's Name: _________________________________________________________________ Social Security Number: ________-_______-___________ Birthdate: _______/_______/_______ Birthplace: ________________________ Mother's Maiden name: _________________________ Is the child covered under a medical insurance plan? YES NO Name of family health care insurance company:_________________________________________ Name of Primary Policy Holder:______________________________________________________ Policy Number:__________________________________________________ Medical History A. List all medications participant is currently taking: ___________________________________________________________ B. List all medical conditions currently under treatment :_________________________________________________________ C. Has the participant lost a paired organ such as a kidney or an eye? If YES, please describe :__________________________________________________ D. Is the participant allergic to any medications? If YES, please list: ___________________________________________________________ E. Does the participant have any known life threatening allergic reactions: (bee or wasp stings, p-nut allergy, etc.) YES NO Please list: _________________________________________________________________________________ F. Date of last Tetanus Immunization: _______/________/________ G. Additional Information:_______________________________________________________________________ (Attach additional page if necessary.) By signing this form you hereby grant permission for your child to be treated in case of a medical emergency. The Newberry County hospital, police, fire and rescue departments are on alert should they be needed at any time. Two-way radio and cell phone communications are used during camp. The law requires the parental permission be obtained for operative procedures on minors in the State of South Carolina. The following consent form should be signed by both parents or legal guardian so that such procedures may be promptly carried out, and so that no unnecessary delays will occur with operative procedures. However, no operation will be performed, except emergency, without parents/guardian being contacted and fully informed first. I give permission for such diagnostic, therapeutic, and operative procedures as may be deemed necessary for my son / daughter. I authorize the release of any medical information to process insurance claims and request payment benefits to the physicians or suppliers for services described. I further understand that I will be financially responsible for payment in full for any charges incurred. I understand that the registration fee for this program does not include any form of insurance coverage. I acknowledge that I choose to release and hold harmless the Camp Conservation Program, Newberry Soil and Water Conservation District, Newberry County, The City of Newberry, NRCS, DNR, or any other businesses or persons, or associates from liability, expenses, damages, losses or costs (including attorney's fee) incurred as a result of the above named child during his/her participation in this program. Signature Mother:________________________________ Date: _______\________\ 20____ Signature Father:_______________________________________ Date: _______\________\ 20_____ Signature of Guardian:_____________________________________ Date: _______\________\ 20____ NOTE- Please also print and sign the RULES ACKNOWLEDGEMENT form ... located on the ABOUT page! THANK YOU!